Sexual Healing by Dr. Margarita Kressin

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

It is my practice to measure testosterone levels on all my patients presenting with erectile dysfunction. We know that testosterone is needed for all sexual function from libido to erection to orgasm. Here I present evidence on the role of testosterone on erectile function. I will also address the claims that testosterone does not affect mood or energy levels or their bodies.

According to the article:

“... there is so little evidence to back up the claim that supplements … help men 45 and older buck up their sex lives, moods, energy levels or bodies.”

Here are some studies for you to consider.

Testosterone and sex lives:

Erectile dysfunction and testosterone deficiency.
Blute M, Hakimian P, Kashanian J, Shteynshluyger A, Lee M, Shabsigh R
Frontiers of Hormone Research. 37:108-22, 2009

Testosterone replacement alone in hypogonadal men can restore erectile function. A significant proportion of men who fail to respond to a PDE5 inhibitor are testosterone deficient. Testosterone replacement therapy can convert over half of these men into phosphodiesterase type 5 responders. It is now recommended that testosterone levels should be assessed in all patients with erectile dysfunction.

Endothelial effects of drugs designed to treat erectile dysfunction.
Aversa A, Caprio M, Rosano GM, Spera G
Current Pharmaceutical Design. 14(35):3768-78, 2008

… endothelial dysfunction is present in testosterone deficiency syndromes and replacement therapy is able to revert ED and to improve endothelial function.

Testosterone and mood

Effects of Testosterone Replacement in Middle-Aged Men With Dysthymia: A Randomized, Placebo-Controlled Clinical Trial
Seidman, Stuart N. MD; Orr, Guy MD; Raviv, Gil MD; Levi, Rachel BA; Roose, Steven P. MD; Kravitz, Efrat BSc; Amiaz, Revital MD; Weiser, Mark MD
Journal of Clinical Psychopharmacology
Issue: Volume 29(3), June 2009, pp 216-221

Testosterone replacement may be an effective antidepressant strategy for late-onset male dysthymia.

Comparison of long-acting testosterone undecanoate formulation versus testosterone enanthate on sexual function and mood in hypogonadal men.
Jockenhovel F., Minnemann T., Schubert M., Freude S., Hubler D., Schumann C., Christoph A., Ernst M.
European Journal of Endocrinology. 160(5):815-9, 2009 May.

Among the 12 items of subjective mood assessment, agitation, self-confidence, activation, good mood and concentration showed a significant improvement during the treatment and further significant improvement during follow-up with TU treatment. The other items, i.e. sociability, listlessness, dizziness, depression, fatigue, anxiety, and aggressivity, improved too, but not significantly. This tendency was the same during the follow-up with treatment with TU.

Partial androgen deficiency, depression and testosterone treatment in aging men.
Amore M, Scarlatti F, Quarta AL, Tagariello P
Aging-Clinical & Experimental Research. 21(1):1-8, 2009 Feb

Abstract: This study provides a critical review of the literature on depressive symptoms of partial androgen deficiency (PADAM) and their treatment with Testosterone (T). PADAM in aging males is responsible for a variety of behavioral symptoms, such as weakness, decreased libido and erectile dysfunction, lower psychological vitality, depressive mood, anxiety, insomnia, difficulty in concentrating, and memory impairment. The psychological and behavioural aspects of PADAM may overlap with signs and symptoms of major depression. Evidence of the relationship between androgen deficiency and male depression comes from studies that have assessed depression in hypogonadal subjects, the association between low T level and male depressive illness, and the antidepressant action of androgen replacement.

Although data derived from androgen treatment trials and androgen replacement do not support T treatment or replacement as more efficacious than placebo for major depressive disorder (MDD), the clinical impression is that, in some sub-threshold depressive syndromes, T may lead to antidepressant benefits.

Testosterone and bodies:

Low bone density and high percentage of body fat among men who were treated with androgen deprivation therapy for prostate carcinoma.
Chen Z, Maricic M, Nguyen P, Ahmann FR, Bruhn R, Dalkin BL.
Cancer. 2002;95: 2136 –2144

Chen et al (2002) investigated the effect of androgen deprivation (removing testosterone) on total body fat mass after 1–5 years of treatment in 62 men with prostate cancer. There was a significant increase in total body fat mass and reduction in lean body mass.

Effects of Testosterone Administration on Fat Distribution, Insulin Sensitivity, and Atherosclerosis Progression
Shalender Bhasin
Division of Endocrinology, Metabolism, and Molecular Medicine, Charles R. Drew University of Medicine Science, University of California — Los Angeles School of Medicine
Clinical Infectious Diseases 2003;37:S142–S149

In spite of the widespread belief that testosterone supplementation increases the risk of atherosclerotic heart disease, evidence to support this premise is lacking. Although supraphysiological doses of testosterone, such as those used by athletes and recreational body builders, decrease plasma high‐density lipoprotein (HDL) cholesterol concentrations, replacement doses of testosterone have had only a modest or no effect on plasma HDL in placebo‐controlled trials. In epidemiological studies, serum total and free testosterone concentrations have been inversely correlated with intra‐abdominal fat mass, risk of coronary artery disease, and type 2 diabetes mellitus. Testosterone administration to middle‐aged men is associated with decreased visceral fat and glucose concentrations and increased insulin sensitivity. Testosterone infusion increases coronary blood flow. Similarly, testosterone replacement retards atherogenesis in experimental models of atherosclerosis.

Testosterone and growth hormone improve body composition and muscle performance in older men.
Sattler FR., Castaneda-Sceppa C., Binder EF., Schroeder ET., Wang Y., Bhasin S., Kawakubo M., Stewart Y., Yarasheski KE., Ulloor J. Colletti P., Roubenoff R., Azen SP.
Journal of Clinical Endocrinology & Metabolism. 94(6):1991-2001, 2009 Jun.

Supplemental testosterone produced significant gains in total and appendicular lean mass, muscle strength, and aerobic endurance with significant reductions in whole-body and trunk fat.

The management of hypogonadism in aging male patients.
Sharma V, Perros P
Postgraduate Medicine. 121(1):113-21, 2009 Jan

Several studies indicate that testosterone replacement therapy may produce a wide range of benefits for men with hypogonadism, including improvement in libido, bone density, muscle mass, body composition, mood, and cognition.

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The Journal Sentinel's claims that "one key problem is that there is a lack of scientific evidence that men over the age of 45 benefit from taking testosterone" is simply untrue. I have presented numerous articles in these posts, all based on scientific and medical research and publications disclaiming their assertion. It is unfortunate that patients are misguided by these articles. Patients should be cautious of what they read in the newspapers and they should always consult their physicians regarding their care and what they read before acting on their own.

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The following is feedback received for this blog: Dr. K - Thanks for writing this rebuttal on that article. Do you know if middle-aged men can do something to increase T without having the actual hormone injections? Something "natural?" - Don Despite claims that the benefits of testosterone replacement therapy aren't supported by research, I have all the evidence I need. I use it myself and, believe me, it works. A daily dose of Testim 1% has significantly improved my sex drive and sexual function. It has given me a sense of mental clarity and accuity that many 50-something men seem to lack. It has dramatically raised my energy level and helped me to add lean muscle mass instead of fat. It may not be the fountain of youth, but it has improved the quality of my life, and that's good enough for me. - Kiernan B. Don, Yes, there have been studies that show increasing muscle mass can increase testosterone production. So start exercising and pumping iron! - Dr. Kressin

This is Part II to my response on the recent Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html


So the article also claimed that

“concerns that it may increase … cardiovascular disease”

Here I present articles published (364 articles matched), most of them within the last 9 months disputing this point. I didn’t have to go beyond the first page of my medline search to get these:

Endogenous testosterone and the prospective association with carotid atherosclerosis in men: the Tromsø study
Vikan T. Johnsen SH. Schirmer H. Njolstad I. Svartberg J. European Journal of Epidemiology. 24(6):289-95, 2009.

In the cross-sectional study, we found an inverse association between testosterone levels and total carotid plaque area (P < 0.05), after adjusting for age, systolic blood pressure, smoking and use of lipid-lowering drugs.

Androgens and cardiovascular disease.
Liu PY, Death AK, Handelsman DJ
Endocrine Reviews 2003 Jun;24(3):313-40

Observational studies show that blood testosterone concentrations are consistently lower among men with cardiovascular disease, suggesting a possible preventive role for testosterone therapy, which requires critical evaluation by further prospective studies. Short-term interventional studies show that testosterone produces a modest but consistent improvement in cardiac ischemia over placebo, comparable to the effects of existing antianginal drugs.

Reduced testosterone levels in males with lone atrial fibrillation.
Lai J, Zhou D, Xia S, Shang Y, Want L, Zheng L, Zhu J
Clinical Cardiology. 32(1):43-6, 2009 Jan

Mean levels of testosterone were significantly lower in subjects with lone atrial fibrillation when compared with controls (476 ng/dl versus 514 ng/dl, p = 0.005). CONCLUSION: Reduced testosterone levels may be associated with susceptibility to lone atrial fibrillation in men.

The dark side of testosterone deficiency: I. Metabolic syndrome and erectile dysfunction. [Review] [121 refs]
Traish AM. Guay A. Feeley R. Saad F.
Journal of Andrology. 30(1):10-22, 2009 Jan-Feb.

The metabolic syndrome (MetS) is considered the most important public health threat of the 21st century. This syndrome is characterized by a cluster of cardiovascular risk factors including increased central abdominal obesity, elevated triglycerides, reduced high-density lipoprotein, high blood pressure, increased fasting glucose, and hyperinsulinemia.

Central or abdominal obesity, measured as WC, is a classical feature of MetS and is associated with reduced total testosterone levels (Pasquali et al, 1997; Svartberg et al, 2004a,b, 2007; Osuna et al, 2006).

Other studies have confirmed the significant inverse correlation between total T and obesity (Pasquali et al, 1991; Laaksonen et al, 2003; Kalyani and Dobs, 2007). Therefore, men with visceral obesity are in a vicious cycle as T deficiency leads to reduced lipolysis, reduced metabolic rate, visceral fat deposition, and insulin resistance.

The dark side of testosterone deficiency: II. Type 2 diabetes and insulin resistance. [Review] [99 refs]
Traish AM. Saad F. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Low testosterone precedes elevated fasting insulin, glucose, and hemoglobin A1c (HbA1C) values and may even predict the onset of diabetes. Treatment of prostate cancer patients with surgical or medical castration exacerbates insulin resistance (IR) and glycemic control, strengthening the link between testosterone deficiency and onset of type 2 diabetes (T2D) and IR. Androgen therapy of hypogonadal men improves insulin sensitivity, fasting glucose, and HbA1c levels. We suggest that androgen deficiency is associated with IR, T2D, MetS, and with increased deposition of visceral fat, which serves as an endocrine organ, producing inflammatory cytokines and thus promoting endothelial dysfunction and vascular disease.

The dark side of testosterone deficiency: III. Cardiovascular disease. [Review] [99 refs]
Traish AM. Saad F. Feeley RJ. Guay A.
Journal of Andrology. 30(1):23-32, 2009 Jan-Feb.

Androgen deficiency is associated with increased levels of total cholesterol, low-density lipoprotein, increased production of proinflammatory factors, and increased thickness of the arterial wall and contributes to endothelial dysfunction. Testosterone supplementation restores arterial vasoreactivity; reduces proinflammatory cytokines, total cholesterol, and triglyceride levels; and improves endothelial function but also might reduce high-density lipoprotein levels.

And finally a few others in summary:

• Diaz-Arnjonilla, et al Intl J of Impot Res 2009 —
  
  • Low T in obese men
  • Lot T in men with metab syn and DM
  • BMI inv propor to serum total T
• Schandt et al Current Opinion in Urology 2009 — Link of androgen deprivation therapy in prostate cancer to development of metabolic syndrome
• Corona et al J of Sex Med 2008 — Low levels of androgens in men with erectile dysfunction and obesity
• Dandona P et al Postgrad Medicine 2009—
  • Hypogonadotropic hypogonad seen in DM2 is assoc with obesity but not duration of DM2
  • 1/3 of DM2 have low T

Two patients of mine recently asked me about the Milwaukee Journal Sentinel article regarding testosterone (T) replacement with the headline, "UW tied to male hormone marketing: Testosterone prescriptions soar despite weak research, risks." Here's a link:

http://www.jsonline.com/features/health/52802117.html

One of them actually stopped it because he became very concerned about T after reading the article. One of them asked me if he should stop it.

So, I was asked to write about this as I do prescribe testosterone, and I want to help ease the potential fears created by this article. Because of the detail of the article and the rebuttal of many points, I thought I would break it into three parts so the important points are not missed. The other two posts will come in the next few days.

I will quote the article and then cite articles that counter the point:

“... concerns that it may increase the risk of prostate cancer…”

1. "The relationship between total and free serum testosterone and the risk of prostate cancer and tumour aggressiveness."
   
   Morote J. Ramirez C. Gomez E. Planas J. Raventos CX. de Torres IM. Catalan R.
   BJU International. 104(4):486-9, 2009 Aug.
   
   CONCLUSION: Prostate cancer risk and tumour aggressiveness are not related to serum levels of total and free testosterone, but hypogonadal patients do not have a greater risk of prostate cancer and tumour aggressiveness.
   
   
2. "Pretreatment serum testosterone and androgen deprivation: effect on disease recurrence and overall survival in prostate cancer patients treated with brachytherapy."
   
   Taira AV. Merrick GS. Galbreath RW. Butler WM. Wallner KE. Allen ZA. Lief JH. Adamovich E.
   International Journal of Radiation Oncology, Biology, Physics. 74(4):1143-9, 2009 Jul 15.
   
   CONCLUSION: Low pretreatment testosterone levels alone did not affect disease recurrence or overall survival. Patients with baseline low testosterone who also were treated with androgen deprivation therapy had a trend toward decreased overall survival.
   
   
3. "Testosterone therapy in hypogonadal men and potential prostate cancer risk: a systematic review."
   
   Shabsigh R, Crawford ED, Nehra A, Slawin KM
   International Journal of Impotence Research. 21(1):9-23, 2009 Jan-Feb.
   
   CONCLUSION: Of studies that met inclusion criteria, none demonstrated that testosterone therapy for hypogonadism increased prostate cancer risk or increased Gleason grade of cancer detected in treated vs. untreated men. Testosterone therapy did not have a consistent effect on prostate-specific antigen levels.
   
   
4. "Testosterone Therapy in Men With Prostate Cancer: Scientific and Ethical Considerations"
   
   Abraham Morgentaler
   Journal of Urology 181 (3):972-79, 2009 Mar.
   
   CONCLUSION: Although no controlled studies have been performed to date to document the safety of testosterone therapy in men with prostate cancer, the limited available evidence suggests that such treatment may not pose an undue risk of prostate cancer recurrence or progression.

Also there have been active research studies in supplementing men with low testosterone who had prostate cancer. If we really thought that T caused prostate cancer, we would never even consider this. These original research studies by some of the leading urologists in the country and the world were presented in the 2008 meeting of the Sexual Medicine Society of North America:

1. "Testosterone therapy in men with untreated porstate cancer on active surveillance"
   
   Morgentaler A, Bennet R, Mohamed O, Chan R, Khera M, LIpshults L
   
   CONCLUSION: Testosterone therapy in 13 hypogonadal men with untreated prostate cancer for a mean of 12 months was not associated with an increase in PSA or substantial rate of grade progression on repaeat prostate needle biopsy. These pilot results suggest that testosterone therapy may be cautiously considered in men with low-risk untreated prostate cancer.
   
   
2. "Testosterone replacement therapy following radical prostatectomy"
   
   Khera M, Grober E, Najari B, Mohmed O, Colen J, Lamb, D, Lipshultz L
   
   CONCLUSION: Testosterone replacement therapy (TRT) is effective in improving testosterone levels in hypogonadal men following radical prostatectomy (RP). In this cohort of hypoogonadal men on TRT after RP there was a significant rise in testosterone values with no significant rise in PSA following TRT.
   
   
3. "Analysis of the PSA response after initiating testosterone supplementation (TS) in patients who have previously received management for their localized prostate cancer"
   
   Davila H, Arison C, Hall M, Salup R, Lockhart J, Carrion R
   
   CONCLUSION: TS by T injection or transdermal gel is effective in improving T level in men following RP and external beam radiation therapy. No significant differences were noted between these groups with regard to PSA levels after TS. This pilot study confirmed consistent efficacy and safety concerning the use of TS after prostate cancer therapy, regardless they type of cancer treatment.

These are just articles within the last year. The urologic community has shifted its thinking on the relationship of testosterone and prostate cancer. The newspaper article did not show or quote any scientific studies. I hope that these studies in our medical and scientific literature can allay some of the questions and fears with testosterone replacement and prostate cancer risk.

A recent article came out regarding inflammation causing female sexual dysfunction. The article -— The Metabolic Syndrome: a Cause of Sexual Dysfunction in Women by K Esposito et al., published in the International Journal of Impotence Research looked at the relationship of the metabolic syndrome and levels of C-reactive protein to female sexual dysfunction.

Metabolic syndrome is a condition defined as having at least three of the following:

• Obesity: In this study, they used abdominal fat as defined by a waist circumference of >102 cm in men (about 40 inches) and >88 cm (about 35 inches) in women
• Low HDL levels (the good cholesterol): (<40 mg/dl in men or <50 mg/dl in women)
• High triglycerides: Elevated triglycerides >150 mg/dl
• Elevated blood pressure: >130/85mmHg
• Abnormal glucose sensitivity: fasting glucose of >110 mg/dl

C-reactive protein (CRP) is a protein produced during systemic inflammation in the body. It has been used to determine risk of atherosclerosis and cardiovascular disease.

This study used the Female Sexual Function Index score to measure sexual function in their study group composed of pre-menopausal women (age range 20-48 years) and controls (a group of similarly aged women without metabolic syndrome). FSFI domains include desire, arousal, lubrication, orgasm, overall satisfaction and pain.

Total score is 36
Good level = >30
Intermediate 23-29
Poor <23

They then compared FSFI, CRP and metabolic syndrome. They found that women with the metabolic syndrome showed statistically decreased score in arousal, lubrication, orgasm and satisfaction.

FSFI scores	Metabolic Syndrome	Control
Good	56%	70%
Intermediate	37%	19%
Poor	9%	2%

They also found that women with metabolic syndrome had lower FSFI and higher CRP levels — 2.2 vs 0.8 mg/L.

So the bottom line is that having the metabolic syndrome can increase inflammation and can lead to bad sex. The key is to keep inflammation down. So take care to keep blood pressure down, keep the bad cholesterol down and good cholesterol up, minding your sugar levels, and keeping the weight down. Not only this is good for the heart and but also for your sex life.

There is a condition known as Persistant Genital Arousal Disorder. It is a condition characterized by spontaneous and unwanted genital arousal characterized as tingling, throbbing or pulsating. It is a serious, distressing, and debilitating condition to the women affected by it. The condition is poorly understood, rare, with limited research and studies in the literature. It can affect any women at any age.

Some causes:

• Neurologic — central and peripheral ^2,3,4
• Pelvic surgery — such as hysterectomy, placement of a sling for stress incontinence
• Pelvic trauma
• Arterio-venous malformation (AVM)² — where the artery and vein have an abnormal connection
• Medication — abrupt cessation of SSRI’s (such as Paxil, Zoloft etc…)^5,6, trazodone⁷, soy⁸
• Malignancy^9,10
• Psychological
• Idiopathic¹¹ (we just don’t know what caused it)

Part of the problem is that most physicians are not aware that this condition exists resulting in frustration and desperation on the part of the patient. Most patients are told that the sensations they are experiencing are in their head, are thought to be “crazy”, or are thought to be seeking attention or narcotics. To be fair, most physicians just don’t know what to do with these patients. I had one patient visit eleven physicians before she ended up in our emergency department and ended up in my care. At that time she did not know what she had and thought that she may really be going insane. She is now going back to her previous eleven physicians educating them about her condition.

I make sure my residents and medical students that rotate through our service know about this condition, so in case they do encounter a patient in the future they will know what to do or where to send the patient. I am putting this in my blog to let patients and other healthcare providers know about this condition. Also, if there is a woman experiencing this condition, she should know that there is such a condition and that there is help for her.

References

1. Leiblum SR, Nathan SG. Persistenst sexual arousal syndrome: A newly discovered pattern of female sexuality. J Sex Marital Ther 2001;27:365-80.
2. Goldstein I, De EJB, Johnson J. Persistent sexual arousal syndrome and clitoral priapism. In: Goldsein I, Meston C, Davis S, Traish A, eds. Women’s sexual function and dysfunction: study, diagnosis and treatment. London: Taylor and Francis; 2006:674-85.
3. Yero SA McKinney T, Petrides G, et al. Successful use of electroconvulsive therapy in 2 cases of persistent sexual arousal syndrome and bipolar disorder. J Ect 2006;22:274-5.
4. Reading PJ, Will RG. Unwelcome orgasms. Lancet 1997;350:2:743.
5. Goldmeier D, Bell C, Richardson D. Withdrawal of selective serotonin reuptake inhibitors (SSRIs) may cause increased atrial natriueretic peptide (ANP) and persistent sexual arousal in women? J Sex Med 2006;3:376.
6. Elmore J, Quattlebaum J. Female sexual stimulation during antidepressant treatment. Pharmacotherapy 1997;17:612-6.
7. Medina CA. Clitoal priapism: A rare condition presenting as vulvar pain. Obstet Gynecol 2002;100:1089-91.
8. Amsterdam A, Abu-Rustum N, Carter J, et al.. Persistent sexual arousal syndrome associated with increased soy intake. J Sex Med 2005;2:338-40.
9. Krychman M, Amsterdam A, Carter J, et al. Brain cancer and sexual health: A case report. Palliat Support Care 2005;2:315-9.
10. DiGiorgi S, Schanatz PF, Mandavilli S, et al. Transitional cell carcinoma presenting as clitoral priapism. Gynecol Oncol 2004;93:540-2.
11. Nappi R, Salenia A, Traish AM et al. Clinical biologic pathophysiologies of women’s sexual dysfunction. J Sex Med 2005;2:4-25

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The following is feedback received for this blog: I read your information on PGAD in which you mention that there is help for this condition. My 27y year old daughter suffers from this condition which began after she was started on birth control medication in Dec. 2008 and experienced a series of side effects following taking this such as dizziness, panic attacks, anxiety, symptoms that she never had before. The dizziness subsided, but anxiety continued. In July 2009 she began to experience involuntary vaginal pulsating sensations and the rest is history. She has been to many different doctors, without improvement. Do you know of a treatment that can help her?? From your experience what medications, treatments have helped other women. Any suggestions would be greatly appreciated. - Renee K. I'm sorry to hear your daughter is struggling with this condition, knowing how challenging it can be. While I can't provide medical advice through this blog, there is treatment available. I would be happy to see your daughter to assess her individual situation and offer treatment, or, depending on your location, point you to a practitioner near her. If you wish, she may contact us to make an appointment at 800-272-3666. - Margarita Kressin, MD I recently had a nerve sparing radical prostatectomy, which was quite successful. While the nerves "heal" (6 to 24 months), I'm undergoing a protocol to maintain the tissues that allow me to get an erection (viagra + VED). I've read one artical about including TRT in this sort of therapy. What are your thoughts on this? - Tim E. Interesting she claims "there is help for her" but the minute someone asks what that help is she "can't provide medical advice through this blog". Probably because she hasn't got any worth hearing!!! There is any kind of medical advice on the net for any condition you want.....this person sounds likes she's dangling a carrot in front of us to get us to make an appointment with her. My guess is she knows no more than any of the dozens of doctors we've all been to. I find references 2, 3, & 7 particularly interesting. Many of us have been in contact with Goldstein....he doesn't know squat!! And electro~convulsive therapy.....I know 3 of us that tried it....2 of us had absolutely no success at all....NONE!!! But I did get something from the ECT's.....loss of memory....parts of my past are gone to me forever.....and for what.....NOTHING!! The other gal has the same residual effect from the ECT's. Thanks to Goldstein's advice, I know my Mother is dead but I have no recall of the event at all.....I don't remember where she lived....I don't remember the cancer....or if I was there for her!!!! I don't remember the surprise 60th birthday party my kids had for me....the fun they say we had scratching off the 60 lottery tickets my son gave me. I was a Registered Nurse....my first love was OB....I couldn't tell you much of anything about delivering a baby!! I hardly remember being a nurse!! Reference 7 (as well as 2) refer to 'clitoral priapism'. We just had interesting notes about this recently. And look at reference 1....she refers to Sandra Leiblum.....Jeannie and I have both met Sandra in person; wonderful lady....she described this syndrome....she named it and has tried to help find a treatment but she makes no claim as to a treatment or cure. While it's good to see that PGAD is being talked about in the medical community, "- Margarita Kressin, MD" has nothing to say that most of us couldn't have said and probably even better. - Nancy B.